1194116616 NPI number — MISS LORENA A. CASTILLO PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194116616 NPI number — MISS LORENA A. CASTILLO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTILLO
Provider First Name:
LORENA
Provider Middle Name:
A.
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194116616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 SAVOY DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30341-1071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-256-4777
Provider Business Mailing Address Fax Number:
404-256-5515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 NORTHSIDE BLVD STE 4600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-7658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-205-5292
Provider Business Practice Location Address Fax Number:
404-205-5291
Provider Enumeration Date:
02/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  7131 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003176164D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003176164E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G15813B . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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